Dr Jeremy Bewley, ICS Council member, shares some thoughts on how we deal with death and how we can improve our approach to death on the intensive care unit.
Recently I attended the emergency department to review an elderly man following a cardiac arrest at home. I arrived to find a very frail 88 year old, intubated by the pre-hospital team, already on our ‘cardiac arrest pathway’ with a CT scan planned and cardiology involved, though not for long. It emerged that he had long standing severe heart failure and metastatic prostate cancer. He was housebound and had been sleeping in a chair downstairs for several months. I reviewed his community notes and found that discussions regarding an end of life care plan and palliative care had been initiated but not completed. It was clear to me that, for this elderly man, this event was sadly unsurvivable. But what, if anything, did ICU have to offer?
Perhaps surprising some and with the luxury of an empty bed, I decided to admit him to ICU for end of life care, with a plan for extubation once his family arrived. When they did I explained that he had, in reality, tried to die at home earlier that day when his heart stopped, at which point they said “that’s exactly what he would have wanted”. He died with dignity, surrounded by his family, in the privacy of a room on intensive care later that night. While it could be described as a ‘good death’, it might have been an even better death if he had died in his own home.
Could a death in ICU have been avoided? When I had read his community notes it was clear that district nurses had been seeing and supporting him at home on a regular basis. I wondered why an experienced district nurse had been unable to initiate a conversation with a patient and recommend a ‘not for CPR’ decision. Why do we have to insist on medicalising these conversations as the recent Royal College of Physicians guidance continues to suggest? Why is it that we all seem to find it so hard to have end of life conversations with patients that could prevent undignified resuscitation attempts pre death?
I recently organised an ICU end of life and palliative care seminar. One reason for the reluctance to discuss dying came up; as a society we have become almost disconnected from death. At this seminar it was widely recognised that the most thought-provoking session was delivered by three experienced ICU nurses on the theme of ‘a good death’. They dramatised the tendency we have to leave a dying patient alone with their family, although with the best of intentions. We find that our attention is too quickly drawn back to a busy ICU full of other critically ill patients as soon as the patient is comfortable, their tubes are out and their machines are switched off.
Yet as this family said, “we’ve never seen someone die”, “how will we know when she has died” and “how do we know if she’s in pain”? As a multidisciplinary team working on the ICU we need to engage our patients, families and palliative care teams to provide the type of environment and support a dying patient would get should they have died at home.
We must also make sure that we don’t view death on the ICU as a failure; we need to retain our humanity and join in the remembrance of the life of the person who is dying or has died. A good example of this is the post death pause; this is when at the end of an unsuccessful resuscitation attempt or unexpected patient death, the whole team pauses to reflect or say a silent prayer to remember the life of the person who has just died. I’ve only done this a few times but each time I was surprised at the way it brought the whole team together at a difficult time.
Finally consider how our society and culture is changing its approach to death when at stadiums we now have a minute’s applause and celebration of a life well served when a top sportsman dies.
Surely it’s time we rethink our approach to death and dying on the ICU?
- Royal College of Physicians Talking about dying: How to begin honest conversations about what lies ahead October 2018